Exploring the experiences of Canadian medical students with a background in the arts and humanities.

Background: Arts and Humanities (A/H) training is a powerful strategy to help medical students develop key competencies which align with the CanMEDS roles that Canadian physicians are expected to embody. Students with backgrounds in A/H may enter medical school with the skills and dispositions that A/H training provides. This paper explores the varied experiences of medical students with prior A/H backgrounds, with an emphasis on how they navigate relationships with their student cohorts and participate in undergraduate medical training environments. Methods: Descriptive qualitative research methodology was used to conduct and analyze semi-structured interviews exploring the perspectives of Canadian medical students with either a A/H degree or training in A/H (n = 13). Domains such as identity, integration of interests, and challenges in maintaining A/H interests during medical training were explored. Results: Participants described their A/H identity as intertwined with their identity as medical trainees and described their sense of interconnection between the disciplines. Challenges included imposter syndrome and difficulties in relating with peers from science backgrounds. Participants described returning to their A/H interests as a tool for wellness amidst medical training. Conclusions: Medical students with a background in A/H training describe this background as offering both affordances and challenges for their sense of identity, belonging, and wellness. These students offer an untapped resource: they come with dispositions of value to medicine, and they perceive a positive, hidden A/H curriculum that supports their maintenance of these dispositions during training. Understanding more about these hidden treasures could help foster the development of well-rounded and humanistic physicians in the entire medical class.

Contexte: Une formation en arts et sciences humaines (A/SH) est une stratégie efficace pour aider les étudiants en médecine à développer des compétences clés qui s'harmonisent aux rôles CanMEDS que les médecins canadiens sont censés incarner. Les étudiants ayant un bagage en A/SH peuvent entrer à la faculté de médecine dotés des compétences et des dispositions qu'une formation en A/SH apporte. Cet article explore les expériences diverses vécues par des étudiants en médecine ayant déjà un bagage en A/SH, en mettant l'accent sur la façon dont ils entretiennent des relations au sein de leurs cohortes d'étudiants et s'intègrent dans des contextes de formation médicale de premier cycle. Méthodes: Une méthodologie de recherche qualitative descriptive a été utilisée pour mener et analyser des entretiens semi-structurés explorant les points de vue d'étudiants en médecine canadiens ayant soit un diplôme en A/SH ou une formation en A/SH (n=13). Des domaines tels que l'identité, la conciliation des champs d'intérêt et les défis liés au maintien de ceux liés aux A/SH pendant la formation médicale ont été explorés. Résultats: Les participants ont décrit leur identité A/SH comme étant intimement liée à celle de médecin en formation et ont décrit leur sentiment d'interconnexion entre les disciplines. Parmi les défis à relever figurent le syndrome de l'imposteur et les difficultés à nouer des relations avec des pairs ayant un bagage scientifique. Les participants ont décrit le fait de revenir à leurs champs d'intérêt liés aux A/SH comme étant un outil de bien-être au courant de la formation médicale. Conclusions: Les étudiants en médecine qui ont un bagage en A/SH le décrivent comme offrant à la fois des possibilités et des défis pour leur sentiment d'identité, d'appartenance et de bien-être. Ces étudiants constituent une ressource inexploitée : ils ont des dispositions recherchées en médecine et ils ont l'impression de profiter d'un curriculum caché A/H positif qui les aide à conserver ces dispositions au cours de leur formation. Mieux comprendre ces trésors cachés pourrait contribuer à favoriser le développement de médecins compétents et humanistes au sein de leur cohorte.

Disorienting or Transforming? Using the Arts and Humanities to Foster Social Advocacy.

Introduction: The arts and humanities (AH) have transformative potential in medical education. Research suggests that AH-based pedagogies may facilitate both personal and professional transformation in medical learners, which may then further enhance the teaching and learning of social advocacy skills. However, the potential for such curricula to advance social advocacy training remains under-explored. Therefore, we sought to identify how AH may facilitate transformative learning of social advocacy in medical education. Methods: Building upon previous research, we conducted a critical narrative review seeking examples from the literature on how AH may promote transformative learning of social advocacy in North American medical education. Through a search of seven databases and MedEdPORTAL, we identified 11 articles and conducted both descriptive and interpretative analyses of their relation to key tenets of transformative learning, including: disorientation/dissonance, critical reflection, and discourse/dialogue. Results: We found that AH are used in varied ways to foster transformative learning in social advocacy. However, most approaches emphasize their use to elicit disorientation and dissonance; there is less evidence in the literature regarding how they may be of potential utility when applied to disorienting dilemma, critical reflection, and discourse/dialogue. Discussion: The tremendous potential of AH to foster transformative learning in social advocacy is constrained due to minimal attention to critical reflection and dialogue. Future research must consider how novel approaches that draw from AH may be used for more robust engagement with transformative learning tenets in medical education.

Leveraging Electronic Health Record Data and Measuring Interdependence in the Era of Precision Education and Assessment.

PURPOSE: The era of precision education is increasingly leveraging electronic health record (EHR) data to assess residents' clinical performance. But precision in what the EHR-based resident performance metrics are truly assessing is not fully understood. For instance, there is limited understanding of how EHR-based measures account for the influence of the team on an individual's performance-or conversely how an individual contributes to team performances. This study aims to elaborate on how the theoretical understandings of supportive and collaborative interdependence are captured in residents' EHR-based metrics. METHOD: Using a mixed methods study design, the authors conducted a secondary analysis of 5 existing quantitative and qualitative datasets used in previous EHR studies to investigate how aspects of interdependence shape the ways that team-based care is provided to patients. RESULTS: Quantitative analyses of 16 EHR-based metrics found variability in faculty and resident performance (both between and within resident). Qualitative analyses revealed that faculty lack awareness of their own EHR-based performance metrics, which limits their ability to act interdependently with residents in an evidence-informed fashion. The lens of interdependence elucidates how resident practice patterns develop across residency training, shifting from supportive to collaborative interdependence over time. Joint displays merging the quantitative and qualitative analyses showed that residents are aware of variability in faculty's practice patterns and that viewing resident EHR-based measures without accounting for the interdependence of residents with faculty is problematic, particularly within the framework of precision education. CONCLUSIONS: To prepare for this new paradigm of precision education, educators need to develop and evaluate theoretically robust models that measure interdependence in EHR-based metrics, affording more nuanced interpretation of such metrics when assessing residents throughout training.

The writer's voice repertoire: Exploring how health researchers accomplish a distinctive 'voice' in their writing.

INTRODUCTION: Much published research writing is dull and dry at best, impenetrable and off-putting at worst. This state of affairs both frustrates readers and impedes research uptake. Scientific conventions of objectivity and neutrality contribute to the problem, implying that 'good' research writing should have no discernible authorial 'voice'. Yet some research writers have a distinctive voice in their work that may contribute to their scholarly influence. In this study, we explore this notion of voice, examining what strong research writers aim for with their voice and what strategies they use. METHODS: Using a combination of purposive, snowball and theoretical sampling, we recruited 21 scholars working in health professions education or adjacent health research fields, representing varied career stages, research paradigms and geographical locations. We interviewed participants about their approaches to writing and asked each to provide one to three illustrative publications. Iterative data collection and analysis followed constructivist grounded theory principles. We analysed interview transcripts thematically and examined publications for evidence of the writers' described approaches. RESULTS: Participants shared goals of a voice that was clear and logical, and that engaged readers and held their attention. They accomplished these goals using approaches both conventional and unconventional. Conventional approaches included attention to coherence through signposting, symmetry and metacommentary. Unconventional approaches included using language that was evocative (metaphor, imagery), provocative (pointed critique), plainspoken ('non-academic' phrasing), playful (including humour) and lyrical (attending to cadence and sound). Unconventional elements were more prominent in non-standard genres (e.g. commentaries), but also appeared in empiric papers. DISCUSSION: What readers interpret as 'voice' reflects strategic use of a repertoire of writing techniques. Conventional techniques, used expertly, can make for compelling reading, but strong writers also draw on unconventional strategies. A broadened writing repertoire might assist health professions education research writers in effectively communicating their work.

Competency-based medical education: The spark to ignite healthcare's escape fire.

High-value care is what patients deserve and what healthcare professionals should deliver. However, it is not what happens much of the time. Quality improvement master Dr. Don Berwick argued more than two decades ago that American healthcare needs an escape fire, which is a new way of seeing and acting in a crisis situation. While coined in the U.S. context, the analogy applies in other Western healthcare contexts as well. Therefore, in this paper, the authors revisit Berwick's analogy, arguing that medical education can, and should, provide the spark for such an escape fire across the globe. They assert that medical education can achieve this by fully embracing competency-based medical education (CBME) as a way to place medicine's focus on the patient. CBME targets training outcomes that prepare graduates to optimize patient care. The authors use the escape fire analogy to argue that medical educators must drop long-held approaches and tools; treat CBME implementation as an adaptive challenge rather than a technical fix; demand genuine, rich discussions and engagement about the path forward; and, above all, center the patient in all they do.

What about Happiness? A Critical Narrative Review with Implications for Medical Education.

Introduction: Despite abundant scholarship and improvement initiatives, the problem of physician wellbeing persists. One reason might be conceptual: the idea of 'happiness' is rare in this work. To explore how it might influence the conversation about physician wellbeing in medical education, we conducted a critical narrative review asking: 'How does happiness feature in the medical education literature on physician wellbeing at work?' and 'How is happiness conceptualized outside medicine?' Methods: Following current methodological standards for critical narrative review as well as the Scale for the Assessment of Narrative Review Articles, we conducted a structured search in health research, humanities and social sciences, a grey literature search, and consultation with experts. After screening and selection, content analysis was performed. Results: Of 401 identified records, 23 were included. Concepts of happiness from the fields of psychology (flow, synthetic happiness, mindfulness, flourishing), organizational behaviour (job satisfaction, happy-productive worker thesis, engagement), economics (happiness industry, status treadmill), and sociology (contentment, tyranny of positivity, coercive happiness) were identified. The medical education records exclusively drew on psychological concepts of happiness. Discussion and Conclusion: This critical narrative review introduces a variety of conceptualizations of happiness from diverse disciplinary origins. Only four medical education papers were identified, all drawing from positive psychology which orients us to treat happiness as individual, objective, and necessarily good. This may constrain both our understanding of the problem of physician wellbeing and our imagined solutions. Organizational, economical and sociological conceptualizations of happiness can usefully expand the conversation about physician wellbeing at work.

An Approach to Leadership Development and Patient Safety and Quality Improvement Education in the Context of Professional Identity Formation in Pre-Clinical Medical Students.

Objectives: Leadership and patient safety and quality improvement (PSQI) are recognized as essential parts of a physician's role and identity, which are important for residency training. Providing adequate opportunities for undergraduate medical students to learn skills related to these areas, and their importance, is challenging. Methods: The Western University Professional Identity Course (WUPIC) was introduced to develop leadership and PSQI skills in second-year medical students while also aiming to instill these topics into their identities. The experiential learning portion was a series of student-led and physician-mentored PSQI projects in clinical settings that synthesized leadership and PSQI principles. Course evaluation was done through pre/post-student surveys and physician mentor semi-structured interviews. Results: A total of 108 of 188 medical students (57.4%), and 11 mentors (20.7%), participated in the course evaluation. Student surveys and mentor interviews illustrated improved student ability to work in teams, self-lead, and engage in systems-level thinking through the course. Students improved their PSQI knowledge and comfort levels while also appreciating its importance. Conclusion: The findings from our study suggest that undergraduate medical students can be provided with an enriching leadership and PSQI experience through the implementation of faculty-mentored but student-led groups at the core of the curricular intervention. As students enter their clinical years, their first-hand PSQI experience will serve them well in increasing their capacity and confidence to take on leadership roles.

Developing and authenticating an electronic health record-based report card for assessing residents' clinical performance.

Purpose: The electronic health record (EHR) is frequently identified as a source of assessment data regarding residents' clinical performance. To better understand how to harness EHR data for education purposes, the authors developed and authenticated a prototype resident report card. This report card used EHR data exclusively and was authenticated with various stakeholders to understand individuals' reactions to and interpretations of EHR data when presented in this way. Methods: Using principles derived from participatory action research and participatory evaluation, this study brought together residents, faculty, a program director, and medical education researchers (n = 19) to develop and authenticate a prototype report card for residents. From February to September 2019, participants were invited to take part in a semistructured interview that explored their reactions to the prototype and provided insights about how they interpreted the EHR data. Results: Our results highlighted three themes: data representation, data value, and data literacy. Participants varied in terms of the best way to present the various EHR metrics and felt pertinent contextual information should be included. All participants agreed that the EHR data presented were valuable, but most had concerns about using it for assessment. Finally, participants had difficulties interpreting the data, suggesting that these data could be presented more intuitively and that residents and faculty may require additional training to fully appreciate these EHR data. Conclusions: This work demonstrated how EHR data could be used to assess residents' clinical performance, but it also identified areas that warrant further consideration, especially pertaining to data representation and subsequent interpretation. Providing residents and faculty with EHR data in a resident report card was viewed as most valuable when used to guide feedback and coaching conversations.

Strategic Paragraphing 2.0: Techniques for Enhancing Inter-Paragraph Coherence.

Most of us pay attention to intra-paragraph coherence: the idea that the sentences within a paragraph should logically develop a single idea. But we forget, or we struggle to master inter-paragraph coherence: the idea that paragraphs should be arranged so that our argument develops logically. Proximity isn't always enough to signal to readers how paragraphs are building on one another to create a compelling argument. Readers may still end up having to infer how one paragraph is linked to the next, and when they can't make those inferences (or they make them incorrectly) coherence suffers. This Writer's Craft offers techniques to enhance inter-paragraph coherence more consciously so that readers don't fall through the cracks between our paragraphs.

Metacommentary: Identifying and Mastering 'Dear Reader' Moments.

You know those worry spots in your paper, the ones you know are there but you're sort of hoping the reader won't notice? They will. Whatever the worry spot, big or small, it needs attention before you consider the paper ready for submission. This Writer's Craft treats these worry spots as "Dear Reader" moments - that is, moments where you should directly address a potential reader concern - and explains how to use metacommentary to achieve this.

The Role of Religious Culture in Medical Professionalism in a Muslim Arab Society.

Purpose: Calls have been made to integrate concepts and practices derived from Muslim culture into medical professionalism in Muslim societies. Little is known about how these religious cultural concepts (RCCs) influence medical practice and education. This study explored the influence of RCCs on medical professionalism in Saudi Arabia. Methods: This was a qualitative study that implemented a constructivist, grounded theory approach. Semi-structured interviews about RCCs and medical professionalism were conducted with 15 Saudi physicians at a single academic medical center. Purposive sampling was used to recruit participants of different genders, generations, and specialties. Data collection and analysis were iterative. A theoretical framework was formulated. Results: Key findings: (i) the role of RCCs in medical professionalism is perceived to be constantly evolving due to the evolution of societal interpretations of RCCs; (ii) participants described applying two standards to judge what is professional: a medical standard and a religious cultural standard. Participants shifted between these two standards variably and non-linearly. This variable shifting altered the values shaping medical professionalism, at times unpredictably. Discussion: Academic Saudi physicians argued against assuming a stable traditional interpretation of RCCs, emphasized the evolving contribution of RCCs to medical professionalism, and indicated that the process of merging religious cultural and medical standards in medical practice is variable and may alter medical practice values. Therefore, these physicians perceived RCCs to be useful as supplements to but not as a backbone for medical professionalism. Careful consideration of the potential impact of RCCs on the values of medical professionalism is warranted.

Supportive and collaborative interdependence: Distinguishing residents' contributions within health care teams.

INTRODUCTION: Individual assessments disregard team contributions, while team assessments disregard an individual's contributions. Interdependence has been put forth as a conceptual bridge between our educational traditions of assessing individual performance and our imminent challenge of assessing team-based performance without losing sight of the individual. The purpose of this study was to develop a more refined conceptualisation of interdependence to inform the creation of measures that can assess the interdependence of residents within health care teams. METHODS: Following a constructivist grounded theory approach, we conducted 49 semi-structured interviews with various members of health care teams (e.g. physicians, nurses, pharmacists, social workers and patients) across two different clinical specialties-Emergency Medicine and Paediatrics-at two separate sites. Data collection and analysis occurred iteratively. Constant comparative inductive analysis was used, and coding consisted of three stages: initial, focused and theoretical. RESULTS: We asked participants to reflect upon interdependence and describe how it exists in their clinical setting. All participants acknowledged the existence of interdependence, but they did not view it as part of a linear spectrum where interdependence becomes independence. Our analysis refined the conceptualisation of interdependence to include two types: supportive and collaborative. Supportive interdependence occurs within health care teams when one member demonstrates insufficient expertise to perform within their scope of practice. Collaborative interdependence, on the other hand, was not triggered by lack of experience/expertise within an individual's scope of practice, but rather recognition that patient care requires contributions from other team members. CONCLUSION: In order to assess a team's collective performance without losing sight of the individual, we need to capture interdependent performances and characterise the nature of such interdependence. Moving away from a linear trajectory where independence is seen as the end goal can also help support efforts to measure an individual's competence as an interdependent member of a health care team.

Using Trainee Failures to Enhance Learning: A Qualitative Study of Pediatric Hospitalists on Allowing Failure.

INTRODUCTION: Attendings allow trainee failure when perceived educational benefits outweigh potential patient harm. This strategy has not been explored in pediatrics, where it may be shaped by unique factors. Our objectives were to understand if, when, and how pediatric hospitalists allow trainees to fail during clinical encounters. METHODS: Using constructivist grounded theory, we conducted semistructured interviews with 21 pediatric hospitalists from a children's hospital in the United States. Iterative, constant comparative analysis took place concurrent with data collection. During regular team meetings, we refined and grouped codes into larger themes. RESULTS: Nineteen of the 21 participants shared that they intentionally allowed failure as a teaching strategy, acknowledging this strategy's emotional power and weighing the educational benefits against harms to current and future patients, caregivers, and trainees. Participants described a multistep process for allowing failure: 1) initiate an orientation to signal that they prioritize a psychologically safe learning environment; 2) consider factors which influence their decision to allow failure; and 3) debrief with trainees. However, participants did not explicitly alert trainees to this teaching strategy. They also avoided using the word "failure" during debriefs to protect trainees from psychological harm. CONCLUSIONS: Most pediatric hospitalists in this study allowed failure for educational purposes. However, they did so cautiously, weighing the educational value of the failure against the safety of both current and future patients, the relationship with the caregivers, and the trainees' well-being. Future research should involve trainees to more comprehensively understand the experience and effectiveness of this teaching strategy.

Trainees' perceptions of being allowed to fail in clinical training: A sense-making model.

INTRODUCTION: Clinical supervisors allow trainees to fail during clinical situations when trainee learning outweighs concerns for patient safety. Trainees perceive failure as both educationally valuable and emotionally draining; however, the nuance of supervised failures has not been researched from the trainee perspective. This study explored trainees' awareness and their experience of failure and allowed failure to understand those events in-depth. METHODS: We interviewed 15 postgraduate trainees from nine teaching sites in Europe and Canada. Participants were a purposive sample, representing 1-10 years of clinical training in various specialties. Consistent with constructivist grounded theory, data collection and analysis were iterative, supporting theoretical sampling to explore themes. RESULTS: Trainees reported that failure was a common, valuable, and emotional experience. They perceived that supervisors allowed failure, but they reported never having it explicitly confirmed or discussed. Therefore, trainees tried to make sense of these events on their own. If they interpreted a failure as allowed by the supervisor, trainees sought to ascertain supervisory intentions. They described situations where they judged supervisor's intentions to be constructive or destructive. DISCUSSION: Our results confirm that trainees perceive their failures as valuable learning opportunities. In the absence of explicit conversations with supervisors, trainees tried to make sense of failures themselves. When trainees judge that they have been allowed to fail, their interpretation of the event is coloured by their attribution of supervisor intentions. Perceived intentions might impact the educational benefit of the experience. In order to support trainees' sense-making, we suggest that supervisory conversations during and after failure events should use more explicit language to discuss failures and explain supervisory intentions.

Will ChatGPT's Free Language Editing Service Level the Playing Field in Science Communication?: Insights from a Collaborative Project with Non-native English Scholars.

ChatGPT has been widely heralded as a way to level the playing field in scientific communication through its free language editing service. However, such claims lack systematic evidence. A writing scholar (LL) and six non-native English scholars researching health professions education collaborated on this Writer's Craft to fill this gap. Our overarching aim was to provide experiential evidence about ChatGPT's performance as a language editor and writing coach. We implemented three cycles of a systematic procedure, describing how we developed our prompts, selected text for editing, incrementally prompted to refine ChatGPT's responses, and analyzed the quality of its language edits and explanations. From this experience, we offer five insights, and we conclude that the optimism about ChatGPT's capacity to level the playing field for non-native English writers should be tempered. In the writer's craft section we offer simple tips to improve your writing in one of three areas: Energy, Clarity and Persuasiveness. Each entry focuses on a key writing feature or strategy, illustrates how it commonly goes wrong, teaches the grammatical underpinnings necessary to understand it and offers suggestions to wield it effectively. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #how'syourwriting?

Ecological interchangeability: supporting team adaptive expertise in moments of disruption.

While undesirable, unexpected disruptions offer unique opportunities to enact adaptive expertise. For adaptive expertise to flourish, individuals and teams must embrace both efficiency and adaptation. While some industries do it readily, others continue to struggle with the tension between efficiency and adaptation, particularly when otherwise stable situations are unexpectedly disrupted. For instance, in healthcare settings, the efficiency mandate for strict compliance with scopes of practice can deter teams from using the adaptive strategy of making their members interchangeable. Yet, interchangeability has been hinted as a key capacity of today' teams that are required to navigate fluid team structures. Because interchangeability - as an adaptive strategy - can generate antagonistic reactions, it has not been well studied in fluid teams. Thus, in this exploratory qualitative study we sought to gain insights into how interchangeability manifests when fluid teams from five different contexts (healthcare, emergency services, orchestras, military, and business) deal with disruptive events. According to our participants, successful interchangeability was possible when people knew how to work within one's role while being aware of their teammates' roles. However, interchangeability included more than just role switching. Interchangeability took various forms and was most successful when teams capitalized on the procedural, emotional, and social dimensions of their work. To reflect this added complexity, we refer to interchangeability in fluid teams as Ecological Interchangeability. We suggest that ecological interchangeability may become a desired feature in the training of adaptive expertise in teams, if its underlying properties and enabling mechanisms are more fully understood.

Protocol for a qualitative pilot study to explore ethical issues and stakeholder trust in the use of normothermic regional perfusion in organ donation in Canada.

INTRODUCTION: The process of controlled organ donation after circulatory determination of death (cDCDD) results in ischaemic injury to organs and leads to poorer outcomes in organ recipients. Although not yet used in Canada, normothermic regional perfusion (NRP) is a perfusion technology used postmortem with cDCDD donors to selectively restore perfusion of oxygenated blood to target organs in situ, reversing ischaemic injury and improving organ viability and post-transplant outcomes. However, NRP poses significant ethical challenges. To preserve trust in deceased donation, these ethical challenges must be addressed to the satisfaction of Canadian stakeholders before NRP's implementation. This study will identify ethical issues pertaining to NRP and explore perspectives of NRP among key stakeholders. By developing an explanatory framework delineating how stakeholder perceptions of NRP's ethical implications impact trust in Canada's donation and transplantation systems, this study will inform the development of responsible policy on NRP's use in Canada. METHODS AND ANALYSIS: This study includes two workstreams. Workstream 1 is a scoping review of medical and bioethical literature to identify ethical issues stemming from NRP. We will apply a common search string across Medline, PubMed (other than Medline) and Embase to identify relevant articles. We will identify grey literature through Google searches, websites of organ donation organisations and consultation with our research network. No date limits will be applied. All peer-reviewed publications, commentaries, editorials or documents that engage with ethical issues in NRP (or conceptual and empirical issues as they relate to these ethical issues) will be included. News articles, conference abstracts and publications not in English will be excluded. Workstream 2 consists of interviews with healthcare providers, institutional stakeholders, organ recipients and deceased donors' family members (n=24-36), as well as focus groups with healthcare providers involved in deceased donation and transplantation (n=20-32). Constructivist grounded theory methodology will guide data collection and analysis in workstream 2. ETHICS AND DISSEMINATION: This study was approved by Western University's research ethics committee (Western REM; ID: 120001). All participants will be asked to provide written informed consent to participate. Findings will be shared with Canadian organ donation and transplantation organisations, presented at national conferences and published in medical journals.